Prevalence and risk factors of elder abuse in survivors of stroke: A cross‐sectional study

Abstract Background and Aims The understanding of the prevalence and risk factors associated with elder abuse in stroke survivors is currently lacking. Therefore, the objective of this study is to ascertain the prevalence and potential risk factors of elder abuse in stroke survivors, while also examining its correlation with insomnia. Methods In this cross‐sectional study, a total of 485 stroke survivors aged 65 years and older, who received treatment at the Emergency department of Shunde Hospital, Southern Medical University, were subjected to face‐to‐face interviews using the questionnaire on elder abuse from the Third Survey on Chinese Women's Social Status. A logistic regression analysis was employed to examine the association between risk factors and elder abuse among stroke survivors. Results 62.27% of the participants reported experiencing elder abuse, with 14.85% of them indicating suffering from more than two subtypes of abuse. Factors such as residing in nursing homes, lower income, and smoking were found to increase the likelihood of experiencing elder abuse and all four subtypes of abuse. Additionally, advancing age was associated with a higher risk of experiencing all four subtypes of abuse, although it did not affect the occurrence of overall abuse. It is worth noting that the self‐reported prevalence of the four types of abuse by the elderly themselves was higher compared to the reports provided by caregivers. Conclusion Elder abuse is prevalent among stroke survivors, especially those who are residing in nursing homes, with lower income, and smokers. Elder abuse significantly increased the prevalence of insomnia in stroke survivors. Further research is needed to better explore effective measures to reduce the prevalence of elder abuse of stroke survivors.


| INTRODUCTION
China possesses one of the highest aging rates globally, with a steadily increasing elderly population that has garnered significant attention. 1 The number of individuals over 60 in China rose from 222 million in 2015 to 264 million in 2021. 2,3 Projections indicate that by 2025, the elderly population in China will reach 280 million by 2025, accounting for 20% of the total population. This aging population has contributed to a substantial increase in stroke prevalence, with an annual growth rate of 8.7%. 4 Statistics reveal that more than half of the world's new stroke cases occur in China each year, affecting around 5.5 million individuals. 5,6 As stroke prevalence continues to rise and medical advancements improve in China, the stroke mortality rate has declined. 7 Consequently, the population of stroke survivors is expected to significantly increase in the future. Stroke patients often face cognitive and physical impairments, leading to a loss of independence in daily activities, and requiring extensive and timeconsuming care. Nevertheless, the growing responsibility of caring for stroke survivors often presents challenges.
Elder abuse refers to the harm or distress inflicted upon elderly individuals through single or repetitive actions, or the failure to fulfill expected responsibilities within a fiduciary relationship. 8 This abuse is a major contributor to a decline in the quality of life, poorer health outcomes, and increased medical burdens among the elderly. It can take in various forms, including physical, emotional, sexual, and economic abuse. 9 Neglect, which is another form of elder abuse, occurs when caregivers fail to meet the basic needs of the elderly, and it often remains hidden. The global prevalence of elder abuse is 15.7%, but it varies significantly across different countries. 10 In China, the third survey of women's social status reveals a prevalence of elder abuse at 13.3%, with emotional abuse being the most common type. 11 Elder abuse prevalence varies between rural and urban areas, with an overall rate of 16.2% in rural areas, which is nearly double that of urban areas. 12 A survey conducted at a prominent medical center in Nanjing, China, involving 412 participants aged 60 or above, discovered that 35% of the subjects had experienced elder abuse. 13  Several studies suggest a potential association between insomnia and an elevated risk of stroke. 16 Chronic insomnia problems may correlate with risk factors for cardiovascular diseases, including hypertension, diabetes, and atherosclerosis, which are also prominent risk factors for stroke. 17 Additionally, insomnia can cause decreased cerebral blood flow, leading to inadequate oxygen delivery to the brain and an elevated risk of stroke. Conversely, stroke can induce sleep disorders, manifesting as difficulties in falling asleep, frequent awakenings, and reduced sleep quality. Pathological alterations in the brain following a stroke, along with disturbances in neurotransmitters, can interfere with the regular regulation of sleep and potentially worsen insomnia symptoms. In summary, insomnia and stroke have a bidirectional relationship, potentially impacting each other in terms of pathogenesis and risk factors. Despite considerable research on poststroke insomnia, its prevalence remains notably elevated among stroke survivors. However, there is currently a lack of reports on the potential association between elder abuse among stroke survivors and the occurrence of insomnia.
This study aims to ascertain the prevalence and potential risk factors of elder abuse in stroke survivors, while also examining its correlation with insomnia through face-to-face interviews. By identifying groups at high risk of elder abuse, the study intends to provide valuable information for screening, intervention, and preven- The study included individuals who met the following criteria: a history of ischemic stroke, age over 65 years, and providing informed consent to participate. Those with psychosis or a negative attitude toward the study were excluded.

| Calculation of sample size
In this study, we determine the sample size by considering the proportion of elder abuse among dementia patients, which is approximately 50%. We applied a 95% confidence level and 5% margin of error. The formula used for sample size calculation is as follows. Taking into account an adopted sample ratio of 1:1.3 and a nonresponse rate of 20%, the final sample size was determined to be 576. Out of the investigators who participated, a total of 485 individuals provided their cooperation, resulting in a response rate of 84.20%.

| Statistical analysis
Data input and analysis were conducted using SPSS 23.0 software.
Descriptive statistics were presented using frequencies and percentages. The initial assessment focused on the prevalence of elder abuse and insomnia among stroke survivors. The association between sociodemographic characteristics of the elderly and the occurrence of abuse, as well as the relationship between elder abuse and insomnia, was examined using the χ 2 test. Additionally, a logistic regression on significant variables during bivariate analysis was constructed to evaluate the connection between independent variables and elder abuse. The analysis results were assessed at a 95% confidence interval (CI), with statistical significance set at a p value <0.05.

| Prevalence of elder abuse among stroke survivors
The study identified a total of 302 cases of elder abuse among stroke survivors, resulting in a prevalence rate of 62.27%. Emotional abuse (138 cases) and neglect (117 cases) were more common than economic abuse (69 cases) and physical abuse (59 cases). Among the participants, 14.85% reported experiencing two or more types of abuse (Table 2).

| Factors associated with elder abuse among stroke survivors
The study found that the prevalence of elder abuse was higher in the   Table S1).

| Prevalence of insomnia among stroke survivors and its association with elder abuse
We conducted an examination to explore the connection between elder abuse and insomnia. The results showed that stroke survivors who experienced elder abuse were more likely to have difficulties in maintaining sleep (χ 2 = 6.3095, p = 0.01) and early morning awakenings (χ 2 = 11.8194, p = 0.00). Additionally, patients who experienced elder abuse reported lower satisfaction with their sleep compared to those who did not (χ 2 = 7.0311, p = 0.01).
However, there was no statistically significant difference in the overall prevalence of insomnia and difficulty falling asleep between the two groups (  23 In our study, we found that 51.3% of the participants experienced sleep disorders, which aligns with previous reports of insomnia rates ranging from 30% to 68% among stroke survivors. 24,25 Insomnia is also considered a potential risk factor for physical disability, dementia, and stroke recurrence. Therefore, our research confirms that elder abuse is associated with an increased risk of insomnia, perpetuating a detrimental cycle involving insomnia, stroke,

ACKNOWLEDGMENTS
We sincerely thank those respected participants who participated in this research.

CONFLICT OF INTEREST STATEMENT
The authors declare no conflict of interest.

DATA AVAILABILITY STATEMENT
The original contributions presented in this study are included in the article/Supplementary material, further inquiries can be directed to the corresponding author's.

TRANSPARENCY STATEMENT
The lead author Zhibo Peng affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.